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Therapeutics II > Pathophysiology and Evaluation of Dyslipidemia > Flashcards

Pathophysiology and Evaluation of Dyslipidemia Flashcards

1
Q

What is the significance of dyslipidemia?

A

-Lipoprotein abnormalities can contribute to increased risk for coronary, cerebrovascular, and peripheral arterial disease
-Coronary atherosclerosis contributes to ischemic heart disease

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2
Q

Examples of lipids

A

-Cholesterol
-Cholesterol esters
-Triglycerides
-Phospholipids

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3
Q

Examples of lipoproteins

A

-LDL
-HDL
-VLDL

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4
Q

Examples of apolipoproteins

A

-Apo-B
-Apo-A1
-Apo-CIII

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5
Q

Symptoms of dyslipidemia

A

-Largely asymptomatic
-Chest pain
-Palpitations
-Sweating
-Anxiety
-Shortness of breath
-Loss of consciousness
-Abdominal pain
-Sudden death

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6
Q

Warning signs of dyslipidemia

A

-Pancreatitis
-Eruptive xanthomas
-Peripheral polyneuropathy
-Increased BP
-Waist size (>40 inches in men) (>35 inches in women)
-BMI over 30

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7
Q

Significant lab parameters associated with dyslipidemia

A

-Increased non-HDL-C
-Increased TC
-Increased LDL-C
-Increased TG
-Increased Apo-B
-Increased CRP
-Increased LDL-P
-Decreased HDL

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8
Q

What is included in a fasting lipid panel?

A

-TC
-TG
-HDL-C
-LDL-C
-Calculated using the Friedewald equation

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9
Q

What is the Friedewald equation?

A

LDL = TC - HDL - TG/5

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10
Q

When is the Friedewald equation not valid?

A

When TG is over 400

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11
Q

How do you calculate non-HDL-C using the Friedewald equation?

A

non-HDL-C = LDL-C + TG/5

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12
Q

What are the non-pharmacologic ways to treat dyslipidemia?

A

-DASH dietary pattern, USDA food pattern, or AHA diet
-Reduce percent of calories from saturated and trans fat
-Lower sodium intake
-Engage in moderate-to-vigorous intensity aerobic physical exercise
-Smoking cessation

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13
Q

What are some examples of foods that would be an appropriate diet to treat dyslipidemia?

A

-Vegetables, fruits and whole grains
-Low-fat dairy products, poultry, fish, legumes
-Non-tropical vegetable oils and nuts
-Limit sweets and red meats

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14
Q

What percent of saturated fats is acceptable when treating dyslipidemia?

A

5-6% calories from saturated fats

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15
Q

How much should you lower daily sodium intake by when treating dyslipidemia?

A

-Less than 1500 mg/day
-Aim for a reduction of at least 1000 mg/day for most adults

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16
Q

How much exercise would people with dyslipidemia do weekly?

A

90-150 min per week

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17
Q

What were the results of the REDUCE-IT trial?

A

3.1% of patients taking icosapent ethyl were hospitalized for AF or atrial flutter compared to 2.1% of the placebo group

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18
Q

What were the results of the OMEMI trial?

A

7.2% of patients taking n-3 PUFA (EPA and DHA) had AF compared to 4% of placebo patients

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19
Q

What were the results of the STRENGTH trial?

A

Omega-3 carboxylic acid-treated group 2.2% had AF compared to 1.3% in the corn oil group

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20
Q

What are the HMG-CoA reductase inhibitors?

A

-Lovastatin
-Pravastatin
-Pitavastatin
-Simvastatin
-Fluvastatin
-Atorvastatin
-Rosuvastatin

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21
Q

What are the low intensity statins?

A

-Simvastatin 10 mg
-Pravastatin 10-20 mg
-Lovastatin 20 mg
-Fluvastatin 20-40 mg

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22
Q

What are the moderate intensity statins?

A

-Atorvastatin 10-20 mg
-Rosuvastatin 5-10 mg
-Simvastatin 20-40 mg
-Pravastatin 40-80 mg
-Lovastatin 40-80 mg
-Fluvastatin 40 mg BID
-Fluvastatin XL 80 mg
-Pitavastatin 1-4 mg

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23
Q

What are the high intensity statins?

A

-Atorvastatin 40-80 mg
-Rosuvastatin 20-40 mg

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24
Q

Which statins are hydrophilic?

A

-Pravastatin
-Rosuvastatin

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25
Which statins are degraded by CYP 3A4?
-Lovastatin -Simvastatin -Atorvastatin
26
Important considerations for statins
-Usually well-tolerated -Obtain LFTs at baseline (DC if LFTs 3x upper limit of normal) -Serious muscle toxicity (myopathy and rhabdomyolysis) -Watch for unusual muscle pain and darkened urine -Avoid large quantities of grapefruit juice (>1 quart daily) -Contraindicated in pregnant women or women who may become pregnant
27
Characteristics that predispose individuals to statin adverse effects
-Impaired renal or hepatic function -Prior statin intolerance or muscle disorders -Unexplained ALT elevations of 3x ULN -Other drugs that affect statin metabolism -Over 75 years of age
28
What to do when patient experiences muscle symptoms or fatigue while on statin
-DC statin and evaluate for rhabdomyolysis -Evaluate for exacerbating conditions -Restart same or lower dose statin once symptoms resolve
29
Statin contraindications
-Acute liver disease -Unexplained, persistent elevations of serum transaminases -Pregnancy -Breastfeeding
30
How do you manage statin treatment for a patient experiencing symptoms of muscle injury?
-Ensure the patient has a valid indication for statins -Assess if muscle pain is exercise-related -DC the statin and see if muscle pain resolves -Switch to a lower risk statin (hydrophilic statins) -Consider alternative dosing strategies -Consider DC the statin/using alternative agents
31
Alternative dosing strategies for statins
-Every other day and once weekly statin dosing has been suggested to improve utilization or tolerability and decrease cost -Initial data for atorvastatin, fluvastatin, and rosuvastatin suggest that double the daily dose is necessary for every other day dosing to achieve similar LDL lowering
32
Contraindications with simvistatin
-Itraconazole -Ketoconazole -Posaconazole -Erythromycin -Clarithromycin -Telithromycin -HIV protease inhibitors -Nefazodone -Gemfibrozil -Cyclosporine -Danazol
33
Which drugs should you not exceed 10 mg simvastatin daily with?
-Verapamil -Diltiazem
34
Which drugs should you not exceed 20 mg simvastatin daily with?
-Amiodarone -Amlodipine -Ranolazine
35
When should FLP be monitored when on a statin?
-At baseline -4-12 weeks following statin initiation -Every 2-12 months, as clinically indicated
36
What are the bile acid resins?
-Cholestyramine -Colestipol -Colesevelam
37
Disadvantages associated with BARs
-May increase TG -Must take other medications one hour before or 4 hours after BAR
38
Adverse effects associated with BARs
-Constipation -Bloating -Nausea -Flatulence -Impaired absorption of fat-soluble vitamins -Hypernatremia -Hyperchloremia -GI obstruction
39
What is cholestyramine contraindicated in?
Complete biliary obstruction
40
What is colesevelam contraindicated in?
-History of bowel obstruction -Serum TG over 500 -History of hypertriglyceridemia-induced pancreatitis
41
What can BARs interact with?
May decrease the effects of: -Acetaminophen -TZDs -Oral contraceptives -Corticosteroids -Ezetimibe -Fibrates -Thiazide diuretics -Warfarin -Digoxin
42
Niacin contraindications
-Active hepatic disease -Significant or unexplained persistent liver transaminase elevations -Active peptic ulcer -Arterial hemorrhage
43
What is the cholesterol absorption inhibitor?
Ezetimibe
44
What is the combination product that contains ezetimibe and simvistatin?
Vytorin
45
How much can ezetimibe decrease LDL by when paired with a statin?
12-20%
46
Adverse effects associated with ezetimibe
-Fatigue -Diarrhea -GI upset
47
Ezetimibe contraindications
-Concomitant use with a statin and active hepatic disease or unexplained persistent serum transaminase elevations -Pregnancy (when used with a statin) -Breast feeding (when used with a statin)
48
Fibrate side effects
-GI disturbances -Rash -Myalgia -Dizziness
49
Fibrate contraindications
-History of gallbladder disease -ESRD or dialysis -Persistent liver disease
50
What can fibrates increase the levels of?
-Statins -Ezetimibe -Sulfonylureas -Warfarin
51
What are the PCSK9 monoclonal antibodies?
-Alirocumab -Evolocumab
52
What are PCSK9 inhibitors indicated in?
Adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or atherosclerotic CVD
53
PCSK9 adverse effects
-GI upset -Increased LFTs -Injection site reaction -Myalgia -Influenza
54
Inclisiran indication
Adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or atherosclerotic CVD
55
Inclisiran adverse effects
-Injection site reactions -Arthralgia -Urinary tract infection -Diarrhea -Bronchitis -Pain in extremities -Dyspnea
56
Bempedoic acid indication
Adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or atherosclerotic CVD
57
Adverse reactions to bempedoic acid
-URTI -Muscle spasms -Hyperuricemia -Back pain -Abdominal pain -Bronchitis -Pain in extremity -Anemia -Elevated liver enzymes
58
Warnings and precautions to bempedoic acid
-May increase blood uric acid levels and lead to the development of gout -Risk of tendon rupture -Avoid concomitant use with simvastatin >20 mg and pravastatin >40 mg (myopathy)
59
What is in red yeast rice that allows it to be used as an additional medication?
Lovastatin
60
How is persistent hypertriglyceridemia defined?
Fasting TG over 150 following at least 4-12 weeks of lifestyle intervention, a stable dose of a maximally tolerated statin, and a secondary cause evaluation
61
What is defined as moderate hypertriglyceridemia?
150-499
62
What is defined as severe hypertriglyceridemia?
over 500
63
Lifestyle modifications to reduce TG
-Targeting 5-10% weight loss = 20% decrease in TG -Very low fat diet (10-15% of diet); restriction of alcohol, sugar, and reined carbs -Moderate or high intensity physical exercise (150 or more min per week)
64
Pharmacologic treatment of TG
Fibrates or omega-3 fatty acids are the go-to

Therapeutics II (33 decks)

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